Page 13 - Microsoft Word - Doc804-Drug&Alcohol Abuse Policy

ATTACHMENT 2

HEPACO, INC.
APPLICANT/EMPLOYEE INFORMED CONSENT
TO DRUG/ALCOHOL TESTING AND RELEASE OF
LIABILITY AND MEDICAL INFORMATION

I understand and agree that under HEPACO’s Drug and Alcohol Abuse Policy, I am required as
an applicant to submit an appropriate specimen for drug/alcohol testing as a part of my pre-employment
physical. Alternatively, as an employee, I understand and agree that I must submit an appropriate
specimen for drug/alcohol testing or submit to other necessary procedures when HEPACO determines
that it is necessary based upon its policies. I understand that an appropriate specimen will be taken in
and analyzed by qualified medical or laboratory personnel.

I understand this analysis will be used to determine the presence, if any, of nonprescribed,
unauthorized or prohibited controlled substances in my specimen.

I freely and voluntarily consent to this request for a specimen. I hereby release and hold
harmless HEPACO, the _______________________ laboratory and Dr./Clinic/Hospital
______________________, their employees, agents and contractors, from any liability whatsoever
arising from the request to furnish an appropriate specimen, the testing of the specimen and any decisions
made on the basis of the analysis. I further freely and voluntarily authorize the ______________
laboratory or Dr./Clinic/Hospital _________________________ to release to HEPACO all test results as
permitted by law.

I understand that a documented chain of specimen custody will be made to ensure the identity
and integrity of my specimen throughout the collection and testing process.

Date Signature of Applicant/Employee

Social Security Number

Date Signature of Witness

Document No. 804: Drug and Alcohol Abuse Policy
Revised December 2000 Attachment 2